rockville, md; tonier cain, team leader and director of peer/consumer involvement, samhsa promoting alternatives to seclusion and restraint through trauma-informed practice, rockville, md; dr. h. westley clark, director, center for substance abuse treatment, substance abuse and mental health services administration, u.s. department of health and human serviceses, rockville, m; dr. maxine harris, ceo and co-founder, community connections, washington, dc. dr. clark, what is trauma and how do we define trauma? the definition of trauma is a little ambiguous, but it's tied to specific adverse events that a person may experience or a community may experience, including disasters, physical or sexual abuse,

or witnessing the above-mentioned. it's of that nature, it could be psychological as well as physical, and there are a wide range of issues associated with the definition. very good, and what are the various sources of trauma? well, the sources are similar to the precipitant. it could be from a relative or a partner. it could be in war, from the enemy. it could be from tornadoes or hurricanes or floods. it could be from predators who are in the community unbeknownst to the victim, a person who's victimized from either physical assault or rape or events like that. so the, it can be from a loved one

or it can be from a total stranger. dr. gillece, basically how is trauma closely tied with substance use and mental health issues? well, we believe that symptoms are adaptations and frequently the way people cope with their trauma is through using, is oftentimes through self-inflicted violence. it's oftentimes with other self-protective issues that people are involved in to protect themselves against the trauma. in mental health we see a lot of diagnoses that are actually trauma related. clearly the posttraumatic stress disorder is one, but a lot of affective disorders are oftentimes really trauma based. a lot of the issues with people with the axis ii or the personality disorders, the people that are labeled borderline personality, we oftentimes see a untreated early experience of physical, sexual abuse, abandonment, neglect, or the witnessing of violence. ms. cain, you're working now

as a peer-to-peer counselor in our center. talk to us about, what was your initial experience with trauma? well, all of my life i've been traumatized. i grew up in a household where i was sexually abused by men in the community that used to visit my mother. and i think i really vivid, a lot of the flashbacks at age 9, i'm pretty sure, probably happened earlier, but a lot of that comes from age 9 is when i realized that, oh my goodness this is not how it's supposed to be, and i started drinking as a result because i couldn't cope with it. at that early age? at age 9, i drank every day. at age 9 because it helped me to numb out what was going on in my life. so, after being in a household of sexual, verbal, and physical abuse, i ended up in foster care and then put into with, placed with a family member, only for my mother to come back to get me

and to be exposed to even more trauma, married at a very young age who my husband beat me and verbally, physically, horrible, horrible abuser. and so the cycle just continued, and at around age 19 because i created a belief system- i am nothing i'll never amount to anything because i thought that these things were supposed to happen to me. so, when someone came to me at age 19 and said "try this," it was crack cocaine; it was the answer to all of my problems. i never had to feel anything ever again. i could just numb out. so, my trauma started very early, and it continued through the system only to be put into services where i was being retraumatized by those that were providing services for me. and dr. harris, is that typical? is that a typical scenario of some of the folks that experience trauma? well, i think what happens is that trauma breaks out of the normal expected life trajectory,

and you're kind of going along and you don't expect the men who come to your house to rape you. you don't expect your mother to go out on a drunk binge and leave you alone. what you think is "normal life" just doesn't happen to you. so you adapt. and you adapt by drinking. you adapt by getting into relationships that may be destructive. you adapt by finding some way to physically or psychologically run away. and dr. clark, this happens, i suspect that because of this dynamic there are an awful lot of people, and we're going to get back to miss cain's experience that end up in our jail systems, that end up in our justice system. is that correct? that is true. there are a lot of people as a result, as miss cain indicated. you start using drugs that are illegal,

and as a result of that you wind up getting arrested, and as a result of that you wind up in jail and then, depending upon the situation, as a result of using drugs you may become violent and you wind up in jail because of that situation, or as a result of numbing out you wind up engaging in "illegal acts" and you wind up in jail. so, a large number of people who are in jail or in prison are there for possession of drugs or for criminal acts associated with drug use and drug abuse. and that is one of the concerns that we have, particularly when many of these individuals have previously been traumatized. and, as dr. harris pointed out, what they're doing is trying to cope with life experiences or situational experiences that are outside the normal range of human experience,

and they cannot find relief any other way. and do we know what the percentage is of the individuals that are in the criminal justice system that experience, have experienced trauma? well upward to eighty five percent we know of women in the justice system, same kind of percentage of girls in the juvenile justice system. i think it's just overwhelming, the number of individuals that are traumatized in these systems. and what we're trying to do is to really develop programs where we start to address what happened to you versus what's wrong with you. i think that was your phrase, maxine, that what was wrong versus, what happened versus what's wrong, so we can start to kind of chisel away at what happened so we can start to build people back up with strength-based kind of programming. and i think women are particularly vulnerable because, if you take a look at it on the sexual abuse side, 1 in almost 20, 1 in 4, it is the statistics that i've seen

and also in terms of domestic violence 15 to 45 percent, anywhere between 15 and 45 percent. so it is, that issue is particularly acute, i think, in terms of what the outcomes may be for the criminal justice system, correct? and i think the multiple systems that you find individuals with trauma histories intersecting with. you can look at the homeless programs, the substance use, the mental health, people in the state hospitals, and juvenile justice. and i think that common thread is that untreated early experience of childhood trauma. and for the men, of course. i mean i think particularly the military comes to mind that you've mentioned before, dr. clark, with the post-traumatic and the traumatic brain injuries that we're experiencing now. well, if you are focusing only on the criminal justice system, military returning veterans often have problems. but you also have to recognize that

there are settings where trauma is common. so ... which are? jails can be, and prisons where there's physical violence or the lifestyle of using drugs where people become vulnerable. there is this gradation in traumatic experiences that we have to take into consideration. women are more likely to be victims of sexual assault, although men are also the victims of sexual assault, but women are more likely. on the other hand, men are more likely to be victims of physical assault or engage in physical assault, so that then puts them in situations where they get incarcerated. the key issue that you're hearing dr. gillece and me mention, and that is making sure we assess for trauma as an integral part of any kind of assessment that we're dealing with. so, we're not dealing with the abuse excuse. what we're dealing with is if, indeed,

we want to break the cycle, we need to start with assessing the situation and informing the victim of what's really going on in their lives and in a way to start dealing with that. it's almost like opening a curtain for that individual to help them see reality. and, when we come back, i really want to focus more on children, youth, and families in trauma. we'll be right back. [music] samhsa has an initiative about trauma and justice, and we're really trying to work with the idea of trauma and its impact on physical illness, its impact on the community's health, and its impact on service delivery systems and what they need to do and their effectiveness. so we are increasingly engaged in a conversation

with other delivery systems, whether it's child welfare systems in which most of the children in that system have suffered some form of trauma in childhood, or whether it's the justice system in which many, many individuals in that system are experiencing trauma and have related behavioral health issues. we talk about trauma-informed care. it is something you screen for. it is also something that you include in the treatment strategy, and in some cases it's so paramount that if you fail to deal with it, you fail to address what's truly going on with the person. so, if a person is a victim of domestic violence, for instance, who presents to you for alcohol and drug use and all you focus on is alcohol and drugs, you're not dealing with the domestic violence. you're not putting that person in a safe environment. you want to return them to a hostile environment, and that certainly will not be good for them in terms of their physical health, but it's also not good for them with regards to the mental health or with regard to the substance-using disorder.

people trapped by drug or alcohol addiction often feel like there's no hope, no way out. but for every lock, there's a key. and if you have a problem it's good to know there are real solutions to help you get free. for drug or alcohol treatment referral for you or someone you know, call 1-800-662-help. brought to you by the u.s. department of health and human services. [music] a little over 7 years ago i was sleeping underneath of a bridge on the streets for 19 years eating out of a trash can, going in and out of correctional and mental health systems. i racked up 83 arrest and 66 convictions all due to my substance abuse because i was

trying to cope with the trauma that had happened in my life. and i would go in and out of prison, and they would say, "this is how you're going to spend the rest of your life, or you're going to die in the streets." once i was able to go to a program where my trauma was addressed, the tamar children program, my trauma was identified, addressed, and treated. i was able to change my belief system from "i am nothing" to "i am somebody," and i can be anything i want in this world. see, when my belief system changed, my thought process changed. and i started to make the best decisions based on me believing that i was worth a better life. dr. harris, let's focus a little bit on issues of trauma for children and youth. you've worked with families, you've worked with children and youth. what has been the typical experience within your center? one of the things that's very interesting is, we see about 500 children a year and almost every child we see has a mother who is also in services, a mother who has been abused,

who has been diagnosed with mental illness, or who is currently abusing substances. so, our children are at least second-generation, sometimes third-generation trauma survivors. and that's called generational trauma, correct? it is a transgenerational phenomena where the traumatic experience is tragically passed from one generation to another, sometimes because mothers who themselves have been victimized do not know how to protect their sons and daughters from the same victimization that befell them. and dr. clark, let's get into the issue of race and ethnicity. this has happened more poignantly within the native american and african american communities in terms of the same phenomena. well, i think trauma happens in every community. we want to make that clear.

now, with regard to the native american community, you've got the common issue of historic trauma, the similar phenomenon in the african american community. and that gives us intergenerational phenomena where you've got abuse, you've got sexual abuse, etc., but the american indian and alaska native communities point to historical trauma as something that needs to be addressed. and, without addressing it, then you wind up essentially blaming the whole community for some of the consequences but, in fact, the community wants to deal with violence against women, incest, these transgenerational traumatic experiences that almost guarantee the next generation is going to have similar experiences. and it goes from one to the other to the other. i want to get back, also getting back to, you've got children, miss cain.

are they in a way, have they received treatment with you in terms of working out some of the issues that you've experienced? i have five kids. four of my kids were taken away from me because of the way that i dealt with my trauma, the substance abuse, the convictions, and all the things that were just symptoms of my trauma, the homelessness of 19 years. so, for four of my kids, as i was giving birth to them -and they were born as a result of rapes and prostitution- were taken away from me. so i ended up in a program. finally, i was imprisoned for violation of parole and i was pregnant again, and i was terrified i was about to lose another baby, and then i found out about this program called tamar children, and dr. gillece is one of the founders of this program. and they said it helps you work on your trauma. i didn't know what trauma was. i figured i had it. i had everything else, your addiction,

your mental health, and your recovery. i had a substance abuse problem. they kept diagnosing me with all these mental health illnesses, so a perfect program, and i was able to keep my baby. and this program was also a program based on how to create and develop a secure attachment with your children, because if you don't know, you don't know. if you don't know how to be nurturing and loving, you come from an abusive household, it takes work sometimes not to be abusive. and i think about what dr. clark said and talking about, i don't think trauma so much as dr. clark would say is not in any other cultures. i just think there were different supports in place for those that had been traumatized and, you know, the caucasians or, you know. it was as important to place, as african american, where something happened to us, we don't go to services. we deal with it the way we deal with it or we go to churches. that's what african americans do, we go to churches for help.

and churches don't know anything about trauma. a lot of trauma happens in the churches. or it goes to the silence within families about traumatic experiences as a family. correct, dr. harris? you know, i think a lot of families keep trauma a secret. this may be true in the african american community but, honestly, i see this across the board. this is the dirty little secret that nobody wants to talk about in public. i think that's the key issue. in fact, we do have a faith-based program at samhsa. the objective is to educate members of the faith community about a wide range of issues-mental health issues, substance abuse issues, and trauma- because we find that the ministers, the rabbis, the imams, the religious leaders do want to know because they're unable to have a positive impact if they're not aware of some of these issues.

we don't ask people to change their philosophical or theological beliefs. we do want them to be familiar with some of the negative consequences that do result from physical abuse, sexual abuse, a violation of trust that happens in households, as miss cain pointed out. and i think it's significant what happens when you tell. were you believed? were you told to keep those dirty little secrets in the house, as dr. harris said, and how you were soothed when you told. there's many folks that we've worked with, many women in the criminal justice system were very clear when they were told they were not believed. they were told to keep that secret in the house. they were told they were making it up. they were told, why were you flirting with my man? and so, what happens when we tell, i think, is really significant. okay, but we can further traumatize, you know, once the person discloses. i think that's one of the main issues. the other factor, we've mentioned the military,

we've mentioned women, and youth and children, and the whole issue of families. another sector of society that also suffers tremendously is the gay and lesbian, the lgbt, community and in particular now with some of the incidents that we have seen on television or violence against them. how do we handle, i mean, are there particular efforts in place to really address those issues? we have a program at community connections specifically for lesbian and transgendered folks. and it focuses in on the additional feeling of disaffiliation, of stigma that people experienced when they tried to come out to family members. there are very few communities, regrettably, where you are easily embraced

when you reveal an alternate lifestyle, so that you may have been traumatized physically or sexually as a child but then, as you come to identify yourself more fully as a person, you're traumatized all over again for your honesty. and we get into also, i mean the whole bullying aspect within the schools, you know, not only against lgbt youth that are experimenting and really haven't made up their minds as to their sexuality, and so on and so forth. but on top of that, then you lay the layer of the trauma in school. correct, dr. clark? well, yes. that's part of the kind of traumatic experience that dr. harris was talking about. and again, working with different agencies, we're trying to educate providers and educators as well as family members about the experiences of lgbt youth

so that we can minimize bullying and offer young people an opportunity to figure out how they want to identify themselves. that's why the phrase that we currently use is lbgtq so that, especially when you're young and you're trying to figure out ... which means? it means questioning. so, there are people who wonder about their sexual orientation. there are people who have decided what their sexual orientation is. some decide early. some decide later. but the key issue is that a person should be able to make that decision without fear of social retribution, whether it's physical or psychological retribution or essentially being banished. so, as dr. harris pointed out, none of the, your peer group but also your family members, and so you're definitely isolated. and it puts you at greater risk because we find a number of lgbt youth are running away, living on the streets, and being the victims of pedophiles

and sexual predators, which just makes life really miserable. so, now they're not dealing with sexual orientation. they're basically dealing with sexual trauma. and i think it's even an issue when the youth are in facility care, residential care. we see it in the residential treatment centers and in services for adolescents, in juvenile detention. so, we see that whole retraumatizing played out again in those facilities. and the reason that we've gone so deeply into really establishing a framework of who's affected is that it's such an insidious problem and it's everywhere, when you really think about it. if you take a look at the populations that are affected, the family certainly encompasses everyone. i'm sure that everyone has one trauma or another in their family. so, when we come back i want to focus on now solutions,

and how do we solve the problem? we'll be right back. [music] before, addiction and depression kept me from living my life. and now, every step i take in recovery benefits everyone. there are many options that make the road to recovery more accessible. it begins with the first step. join the voices for recovery. for information and treatment referral for you or someone you love, call 1-800-662-help. brought to you by the u.s. department of health and human services. recovery benefits everyone. i started my own company. i got my dad back.

my friends believe in me. substance use and mental disorders can be treated. it all starts on day one. join the voices for recovery. for information and treatment referral for you or someone you love, call 1-800-662-help. brought to you by the u.s. department of health and human services. [music] community connections is the largest not-for-profit mental health agency in the district of columbia.

we serve probably about 3,500 women, children, and men who are frequently dually diagnosed, have histories of homelessness, and have histories of traumatic victimization. the mission of community connections, first of all, is mental health, making everybody whole, of the people who have suffered from trauma, people who have substance abuse, to give you the tools to be able to manage your mental health issues and your trauma issues such as ptsd, to make you to be able to function on the outside in public despite what things have happened to you. sisters empowering sisters is a program for women who are dually diagnosed with a psychiatric illness and addiction and who are the victims of violence to serve as peer mentors

for other women who have similar histories. i loved the peers. i have to talk about that because i could talk to any of them. they're very understanding. they have a whole lot of strength with them and confidence, and you could talk about... and they make you feel so welcome. and then they give you that love and that caring and that respect. peer recovery support services are consumers helping other consumers. we've been through training, and we facilitate groups on various topics, from women's health to trauma survival, substance abuse issues with different topics each week from, for instance, evaluating relationships, red flags for domestic violence, and things of that issue that women struggle with. and we also have a computer lab, and we're here to assist you in developing a resume or online job searches. one of the goals is to promote a positive supportive environment

to foster women's growth. and another goal is to increase the knowledge of local resources that are welcoming and responsive. i just like the atmosphere. it's a good spirit in that center because it's women that understand what you're going through. so, groups is where it's based on everybody giving feedback about a topic. so it's like we're just, it's a women's rap. so we're just constantly sharing our experiences and what we hope our goals would be, and it's just empowering because you don't feel alone. i think a lot of people don't understand that how men deal with trauma and substance abuse issues are different from how women deal with trauma and substance abuse issues. being able to feel heard and understood, being able to believe that the cycle of violence

is something that can be interrupted is something that restores hope to people. and i've talked to a number of women and said, "well, why couldn't you do this on your own?" and people will say, "you know, i had lost all sense of motivation. i had lost all belief that the future could be better than the past. it seemed that i was trapped in a kind of cycle where bad things repeated themselves over and over and over again." and sisters empowering sisters gives women a sense that the future can be different. my life was very unstable before i found recovery. now that i have recovery i have a purpose. i have a reason for living. i have direction. i have goals. i have peace. dr. clark, what is trauma-informed care? well, listening to dr. harris and dr. gillece,